Effects of sensate focus technique and position changing on sexual function of women with deep-infiltrating endometriosis after surgery: A clinical trial study

Abstract Background Endometriosis is a disease that affects women throughout their sexual life. Sexual health is, therefore, a major concern for these women. Objective This study aimed to assess the effects of the sensate focus technique and position changing on the sexual function of women with deep-infiltrating endometriosis 3-6 months after surgery. Materials and Methods This clinical trial study was performed on 80 women with deep endometriosis, aged 18-45 yr, who were referred to the endometriosis clinic of Avicenna fertility center, Tehran, Iran for follow-up after surgery from January to September 2021. They were divided randomly into 2 groups. In the intervention group, 2-hr virtual training sessions were held and the control group only completed the questionnaires without any intervention. Sexual function was evaluated after 4 and 8 wk. Results 8 wk after the intervention, the mean score of sexual function in the intervention group was significantly improved (p < 0.001). The mean total score of sexual function in the pre-intervention period reached from 24.16 to 28.31 in 4 wk after the intervention and 29.85, 8 wk after the intervention. The mean score of sexual pain during the follow-up periods was significantly improved in the intervention group (p < 0.001). Conclusion Sensate focus technique and sexual position changing improved sexual function in women with deep endometriosis after surgery.


Introduction
Sexual function is one of the most critical dimensions of human life (1). It can impact all aspects of a couple's lives (2). The origin of sexual dysfunction may be due to a psychological condition or a social, biological, medical, or a combination of these factors (3). Sexual dysfunction is a prevalent issue and affects 41% women of reproductive age worldwide (4).
The overall prevalence of sexual dysfunction among the reproductive-age women in Iran was estimated as 52% (5). Several factors are involved in developing and emerging women's sexual dysfunction, and endometriosis is one of them (6).
Endometriosis is defined as the presence of endometrial tissue (endocrine or stroma) outside the uterine cavity (7), and there is a relatively common condition, with its prevalence reported in 15% of women of reproductive age (8,9).
Deep infiltrating endometriosis (DIE) is the most severe form of endometriosis, associated with the peritoneum or peritoneal layer with a depth of 5 mm (10).
The most common symptom of endometriosis is chronic pelvic pain, dysmenorrhea, dyspareunia, sexual dysfunction, and infertility which can significantly affect women's quality of life and mental health (11). In a study conducted on 51 Indian women with endometriosis, it was found that 47% of patients had sexual dysfunction.
With increasing staging of endometriosis, the prevalence of sexual dysfunction also increased (12). The prevalence of sexual dysfunction in women with endometriosis is about 61% (13).
Dyspareunia can be observed in 60-70% of women with DIE after their surgery and can lead to sexual dysfunction, and cause negative effects in their relationships (14). Surgery can have a positive effect on endometriosis symptoms (15) but does not necessarily lead to definite solving of their sexual problems. Researchers have recently used different interventions to improve sexual activity and sexual satisfaction in women (16).
The research has shown that providing couples with interventions can help them improve their relationship (17). One of the interventions is the sensate focus technique, introduced by Masters and Johnson as a couple-based intervention that includes sensual touching and cuddling (18). Some studies showed strong evidence about sensate focus technique's effectiveness in treating various types of sexual dysfunctions (19).
A study showed that some sexual positions reduce pain during intercourse. The "missionary position", "woman on top", the "spoon position", and "vaginally from behind" are possible positions in intercourse despite dyspareunia in women with endometriosis (20).
Endometriosis, especially deep infiltrated lesions, disrupts the sexual function of women, which is destroyed due to pain, depression, or frustration. These problems remain even after surgery (21). Medications and surgical treatments may only suppress the symptoms, but they do not treat them. Also, due to the mechanical impact of pain in women with endometriosis and the fact that even after the surgery, the negative mental effects of the disease are present. Although surgery has a significant effect on reducing pain severity, it will be ineffective on psychological effects (22). So, we decided to investigate the effect of the sensate focus technique and sexual position changes on the sexual function of women with DIE 3-6 months after surgery.

Study design
This parallel non-blinded clinical trial study was conducted on 80 women admitted to the Endometriosis Clinic of Avicenna Fertility Center, Tehran, Iran, 3-6 months after surgery, from January to September 2021.

Inclusion criteria
Married women aged between 18

Exclusion criteria
The couple's unwillingness to stay in the study, getting pregnant while studying, failure to perform a regular intervention program, and remaining severe surgical complications (according to the research unit and the file).

Randomization
Participants were randomly assigned to research groups using random numbers table.
Paired and individual methods were used to assign samples to the intervention and control groups. Even numbers in the random number table were assigned to the intervention group, and odd numbers to the control group.

Sampling
The sample size in terms of total sexual function score, 1 month after the intervention in the 2 control and intervention groups with a sample size of 10 people, as a pilot, was calculated for each group, using the below formula, as 36. With an estimated drop of 10%, it was calculated as 40 (80 in total). The mean of the 2 groups was 24.65 and 27.55, respectively, and the difference in standard deviation was 3.1, with power level (1-beta) = 0.8 at the alpha threshold = 0.05.

Data collection tools
The data collection tool in this study were

Statistical analysis
Data were collected and analyzed using SPSS

Results
Out of 80 participants, 2 in the intervention group and 2 in the control group were excluded from the study due to pregnancy. Finally, the data analysis was performed on 76 women who completed the intervention (Figure 1) (Table II).
The results showed that only the level of education of participants in the control and intervention groups showed a significant difference (Table III). However, the covariance analysis showed no significant relationship between the level of education and sexual function (before the intervention, 1 month after intervention, and 2 months after intervention) (Table IV).
According to Mann-Whitney U test results, the mean total score of sexual function in the pre-  (Table VII).

Discussion
This Astudy showed that the "missionary position", "woman on top", the "spoon position", and "vaginally from behind" were used during intercourse despite dyspareunia in women with endometriosis (20). This study's results were inconsistent with ours, which could be due to differences in the research participants (partners of women with and without endometriosis).
A study investigated the major and minor It should also be noted that the participants did not take the hormonal drugs after surgery, and this factor itself may imply pain. A study evaluated the deep dyspareunia 6 months after the complete removal of endometriosis using laparoscopy with the preservation of the nerve. They found a significant decrease in dyspareunia at a 6-month follow-up, but some women did not experience any improvement in their dyspareunia, and in some cases, the condition deteriorated or manifested itself for the first time (31), which can be explained by another study, which concluded that the severity of pain experienced by women who have endometriosis may be the predictor of their response to surgery (32).
The present study has not evaluated the sexual function of women's spouses, it is suggested that in future studies, the sexual function of couples be performed simultaneously, and the results be compared with each other.

Conclusion
The results of our study show that the sensate